MEDICAL LITIGATIONS IN ANESTHETIC PRACTICE IN SAUDI ARABIA SPECIALTY

MEDICAL LITIGATIONS IN ANESTHETIC
PRACTICE IN SAUDI ARABIA
THE WHOLE PICTURE AND THE DILEMMA OF THE
SPECIALTY
- Administrative Prospectives M OHAMED ABDULLAH SERAJ *
Recently an article caught my attention by Dr. Ahmed Alsaddique
entitled “Medical Liability”- The dilemma of litigations1. This article
represents the true picture of litigations against various medical
specialties in the health care system in Saudi Arabia. It is to be noted that
the speciality of anesthesia ranked seventh in the number cases submitted
for litigation, and revives memories of a once serial articles entitled,
“Dilemma of Anaesthesiologist working in Saudi Arabia”2-5.
The authors of those articles2-5 illustrated the daunting facts existant
in the absence of guidelines on standard of care and proper monitoring,
non-existent policy and procedures, the appalling working facilities in
peripheral hospitals, single handed working anesthesiologist, the
unhelpful attitude of administration, who can order any physician to
perform certain tasks beyond their capabilities and the psychological
torture, frustration and agony of being involved in a legal case and being
convicted without a fair trial. etc2-5.
Those series of articles2-5 appeared 14 years ahead of the recent Dr.
Alsaddique article1. It pointed out that the dilemma is a multi-disciplinary
one and is shared by three components: The Ministry of Health (the
governing body), the Saudi Anaesthetic Association (SAA) and the
*
FRCA, Professor of Anaesthesiology Director of Anaesthesia and Intensive Care, Riyadh Armed
Forces Hospital. KSA.
Tel: 00966 1 4777714, Ext. 5288, 5241. Fax: 00966 1 4777714, Ext 2960.
707
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MOHAMED SERAJ
Specialist (The practitioner).
The authors of those articles2-5 stipulated all problems encountered
by colleagues in their daily work and the cases of malpractice submitted
against some members of the specialty. They gathered all necessary and
essential information and were advisories to the legal medical court and
gave their opinion on several occasions. The authors insist every time that
they attended these medical legal court procedures or gave written
consultation that a postmortem should be a mandatory part of the
investigating procedure. This will provide the ultimate diagnoses and
allows fairness to the specialty, the plaintiff and the defendent. The
authors indicate that western countries are using postmortem to reach the
accurate cause of death in obscure illness or unexpected death in a
litigation case.
In the past litigation discussion took place in one central court where
all cases were dealt with. The procedure was long and daunting. Some
times it took between two-three years or longer before a verdict was
reached. During this period the defendent could not travel, received less
salary and was not allowed to practice anesthesia at all. Once the verdict
was handed down and the blood money paid, the defendent had to leave
the country. Two anesthesiologists who were subjected to this ordeal
suffered heart attacks and died during or after their conviction due to the
overwhelming stress of the enquiry. In view of the above the authors
ended with these recommendations:
I. Role of the Governing Body (GB), (The Establishment)
The authors2-5 gathered statistics of anesthetics performed, the
number of anesthetists working in Ministry of Health (MOH) and Private
Sector (PS) and Other Government Hospitals (OGH) The authors found
out that both the MOH and the PS anesthetists have, more work load per
year, they are less qualified carrying lower degrees, and are not insured
when compared with anesthetists working in the OGH. In addition they
were more involved in litigations and convictions than anesthetists
working in OGH.
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Statistics indicate that the MOH controls about 82% of the health
care delivery system in Saudi Arabia and that they have medico-legal
litigations submitted against them. From the above findings we ask
ourselves. Does MOH have any roles? As the MOH is considered to be
the governing body or the guardian of the health care delivery system in
the Kingdom, doubtless it has major roles to play toward members of the
specialty.
The authors2-5 targeted the MOH with specific recommendations
aimed at improving the service in the specialty of anesthesia; the
recruitment policy and procedures that have to be implemented and
enforced, the provision of better salaries for Saudi and expatriates
specialists with the purpose of attracting top class-personnel,
implementing the national standard of care monitoring created by the
Saudi Anaesthetic Association (SAA) and establishing detailed policies
and procedures for the specialty be it administrative, professional or
educational. The above mentioned sets of criteria are urged to be
implemented and enforced. This also must be coupled with an excellent
biomedical department.
Mandatory requirement of an ongoing education was indicated by
His Excellency Dr. Ghazy alQusabi, the former Minister of Health. All
members of the specialty and other health providers must be allowed to
attend symposia, courses and workshops in order to improve their
knowledge and skills with the objective of promoting the quality of
medical services to patients. These objectives, however, were never
implemented by health authorities in both the MOH and the private
sector. Needles to ad that all hospitals should have proper computerized
monitoring in order to reduce or even prevent poor documentation.
II. Role of the Saudi Anaesthetic Association
The newly established Saudi Anaesthetic Association (SAA) had
invited top consultants and academicians in order to propose
recommendations for the anesthetic services in the Kingdom as a whole.
The main objective was to update the system and improve the services in
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our specialty to become commensurate to western associations who have
actually become guardians of the specialty.
Western societies have set standards of care monitoring and policy
and procedures that have been applied through out the health care system
world wide. Anesthetists all around the world are using the American
Society of Anesthesiologists (ASA) classification and standard of care. It
is felt that there is need to develop a KSA standard of care with local
application similar to ASA standards.
Our recommendations to the SAA consists of the following
procedures:
1 - To have a long term national survey on the anesthesia services in
the Kingdom.
2 – To establish national standards of care and monitoring that have
been applied in the university hospital but unfortunately not applied by
the majority of hospitals. These recommendations were published in two
parts in the Newsletter of the SAA vol. 1, no. 3 and 4 May and July 1990.
3 – To put forward the approved policies and procedures for the
anesthesia services in the Ministry and private sector hospitals.
4 – Provide continuous medical education: regular scientific
meetings and courses for updating the knowledge and the skills of the
working anesthetists.
5 – To provide top class library.
6 – To provide malpractice insurance known as Al-takaful elejtemaei. This system requests each member of the department to deposit
S.R. 2000. The proceeds can be used to pay the blood money for
conviction of any member of the department. One advantage of this
insurance coverage is that each member can withdraw the sum of money
belonging to him or donated to SAA when he/she finish their work in the
department, applicable only if blood money has not been paid. This
insurance coverage was first initiated by the SAA in the Anaesthetic
Department of the University Hospitals and later was offered to all
members of the Association even to every anesthetist working in the
Kingdom6. Unfortunately, higher authorities in the health care delivery
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system had never advised their staff to join in. The MOH still has the
same lack of interest toward the specialty.
III. The Practitioner (Specialist)
It is advised that the specialist practitioners be forearmed with the
following important virtues promoting competent anaesthetists. Ten
commandments are presented7,8: Be safe, punctual, diligent and tactful to
all, vigilant, and able to perform a wide varieties of anesthesia harmlessly,
never leave the patient unattended, be able to solve problems, expect the
unexpected, admit self-limitation and seek advice, carry out immediate
documentation, proper charting, accompany patients to the recovery room
and see that discharge orders are prescribed, signed and approved by him
all the time, and attend scientific meetings regularly, and be a holder of a
valid certificate in BLS and ACLS.
What Has Been Implemented and Achieved?
As the only Professor of Anesthesiology in the Kingdom and the
Chairman of the newly established Department of Anaesthesia in the
Medical College of King Saud University (KSU) and the University
Hospitals and President of the SAA, I took the liberty of defending the
specialty by writing several memos to His Excellency, the previous
Minister of Health, Professor Osama Shubokshi in which I detailed the
status of the anesthesia service and CPR in the Kingdom. Furthermore, I
also had the honor of an audience with His Royal Highness Prince Naif
Ben Abdulaziz Minister of Interior at which time I submitted to him the
critical and important recommendations that were issued and circulated to
the health care system in the Kingdom with the objective of presenting an
actual and clear picture of anesthetic practice and its pitfalls, in the
Kingdom..
My efforts ultimately resulted in two meetings between several
health authorities in the Kingdom, mainly representatives of the MOH,
the Saudi Council For Health Specialty (SCFHS) and the SAA. In
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addition a further report was submitted to His Royal Highness Prince Naif
on the outcome of these meetings including future recommendations and
measures that have been adopted to improve the service. Suggestions
were also raised to promote income in order to encourage recruitment of
new Saudi and expatriates anesthetists.
Parallel to these accomplishments the AAS has initiated regular
annual scientific and monthly club meetings and most recently, started
new venture of outreach programs. All these activities have been
accredited by the SCFHS as Continuous Medical Education (CME).
The Future
Pending issues yet to be resolved in the Kingdom:
I. The formation of the medico-legal courts
a.
Are there a set of rules and regulations governing the formation of
the various regional courts?
b.
Who are the members of the medico legal courts?
c.
Are there any differences between regions?
d.
Are there any differences between the Kingdom’s medico legal
courts and other countries? (Overseas medical courts allow lawyers
to defend the accused. This is not applied in SA courts).
2. The application of postmortem as a diagnostic tool
In SA, postmortem is only sometimes used, as the ultimate
diagnostic tool in a criminal act. Whereas it should be made should
mandatory in all cases in order to protect the specialty, the plaintiff and
the defendent and that no legal proceedings should start without a post
mortem. When implemented, the widely used conviction based on
speculations will be a abolished in the country. Most of the time,
members of the courts call on their medical expertise to read file notes in
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order to solve the medical puzzles they are facing, and most members use
“the magic crystal ball”, in order to reach the right judgment. This
practice is not fair for either the plaintiff, the defendent. or the specialty.
3. Other measures
Measures yet to be enforced on the Ministry and private hospitals.
a.
Approved detailed policies and procedures (P.P.). Medical
professionals cannot be prosecuted unless he/she receive the approved
policies and procedures of the Department on which he/she is expected
to fully comply with. Most of the MOH and private sector hospitals
have no P.P. and without P.P. the governing body cannot condemn the
specialist and simply “release the guillotine”.
b.
Application of the newly recommended policies to recruit top class
expatriate professionals.
c.
Request highest authority in the Kingdom to approve a different and
new scale of salaries for physicians carrying rare specialties and
subspecialties a procedure already achieved in the western world.
A question poses itself as to why is it that some specialties who
work only day duty, are on call at homes and hardly, or never, attend,
serious and life threatening cases during their call duty, collect the same
salaries as those (anesthetists) working the same day duty plus nights and
week ends and are actually dealing with life threatening emergencies?
d.
Enforcement of an on-going CME credit hours on all medical
professionals: attending regularly symposia, conferences, and
workshops to collect the necessary credit hours needed to obtain the
license to practice medicine in the Kingdom.
e.
Computerized documentation. Modern technology is available and
should be an integral part of practice in monitoring anesthetized
patients all the time and any where in all hospitals. This will reduce
or prevent the likelihood of fabrication of charts in patient’s file,
lying or shifting responsibilities onto other innocent staff.
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f.
Adopting the national standards of care and monitoring in all
hospitals are the responsibilities of The Ministry and the private
sector. This national standard of care and monitoring was established
by the SAA and implemented in most of the referral of other
government hospitals.
g.
All major and referral hospitals of the Ministry of Health should
submit for accreditation by the Saudi Board of Anesthesia and
Intensive Care residency training program. The aim is to qualify
these hospitals with the standard required by the board of SCFHS
and have Saudi residents joining the specialty become the future
specialists responsible to manage supervise and/or be in charge of
running the daily routine work in the departments after graduation.
These important measures will ultimately make the difference
between lower and upper class of standard of care in medical practice in
the Kingdom.
Personal Reflections
In the seventies, anesthesia practice was till in its beginnings. Most
hospitals had limited facilities when compared to facilities in the western
world where we trained and practiced. Then I was the only practicing
Saudi anesthetist, in the medical school and university hospitals of King
Saud University.
The task of introducing modern practice of anesthesia to the
Kingdom was huge and daunting one. The country was short of
specialists in our field. A colleague ahead of me, in an attempt to increase
the work force in anesthesia, had introduced a technician training
program to produce technician graduates and established a technician
diploma degree in order to cover gaps in the service in the specialty.
In the eighties, few colleagues after having obtained high degrees in
the specialty returned to the Kingdom from England, Germany and
Canada. They were the new and badly needed work force.
The nineties initiated the golden era of the specialty. Three higher
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degrees were established in the Kingdom starting with Fellowship in King
Saud 1989, The Arab Board in 1993 and the Saudi Board 1998. The
Saudi Board was established to have a four year residency training
program based on the Canadian system of training, and the modern arts of
anesthesia teaching can be said to have been introduced to the country.
At the beginning residency training program was not popular to
medical graduates as the specialty became known as the specialty of
“Unknown Soldier”. Only few residents joined the program who
graduated earning one or all three degrees.
For the last 2 years, however, more than 20 new residents per year
have joined the training program and the new graduates occupied leading
posts in different hospitals of the country. In the mean time several
overseas graduates returned which facilitated an advanced competency in
the practice of anesthesia. With the establishment of the Saudi
Anaesthetic Association (SAA) in 1989 a vast and immeasurable
difference to the specialty was affected. The number of Saudi anesthetists
increased 100 times during the last 20 years to reach 200. Over 80 carry
high degree and 120 are residents (98 residents are in the local residency
training program, while the rest are in overseas scholarship).
The new century witnessed further advances in the development of
higher degrees in the following fellowships:
a.
Cardiac anesthesia.
b.
Critical care medicine.
c.
Pediatric anesthesia. Recently and approved by the Saudi Board of
Anesthesia and Intensive Care.
d.
Pain management (Under preparation).
These fellowships consist of intensive training programs. A
candidate spends two years in a specific sub-specialty, following which
the candidate obtains the fellowship degree.
The SCFHS had great impact on the medical field by taking over the
major role from post graduate department of the medical schools that
started these resident training programs earlier in the eighties. The
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SCOHS developed a wider spectrum of higher degrees in other
specialties, and introduced the ruling that no one can practice medicine in
the Kingdom without having his/her degree recognized and equalized, and
imposed a mandatory CME credit hours in order to obtain the Saudi
license to practice in the Kingdom.
Finally I an not alone in the specialty anymore. I am honored to have
been the first anesthetist and proud with what I have started, implemented
and accomplished throughout my career during the past thirty years. I am
sure and confident that the new graduates are up to the challenges facing
them. I hand them the banner to carry on the good work expected of them.
References
1. AL-SADDIQUE A: Medical liability. The dilemma of litigations. Saudi Medical Journal; Vol. 25,
2004.
2. SERAJ M, CHANNA AB: Dilemma of anaesthesiologist working in Saudi Arabia. News letter of the
Saudi Anaesthetic Association. Part I, Vol. 3, No. 3, and Vol. 3, No. 4, July 1992.
3. SERAJ M, CHANNA AB: Dilemma of anaesthesiologist working in Saudi Arabia. News letter of the
Saudi Anaesthetic Association. Part II, Vol. 3, No. 4, October 1992.
4. SERAJ M, CHANNA AB: Quality assurance and risk management (Malpractice insurance). News
letter of the Saudi Anaesthetic Association. Par IV, Vol. 4, No. 1, January 1993.
5. SERAJ M, CHANNA AB: Dilemma of anaesthesiologist working in Saudi Arabia. News letter of the
Saui Anaesthetic Association. Part IV, Vol. 4, No. 1, April 1993.
6. SERAJ M: Malpractice medical insurance for anaesthesiologists. Al-Takaful Al-Ejtemaie (T.E.)
News letter of the Saudi Anaesthetic Association. Vol. 2, No. 4, November 1991.
7. SERAJ M: Ten commandments for anaesthetists. News letter of the Saudi Anaesthetic Association.
Vol. 2, No. 1, January 1991.
8. SERAJ M: The perfect anaesthetist should be, News letter of the Saudi Anaesthetic Association.
Vol. 5, No. 3, July 1994.